食管胃底静脉曲张破裂出血内镜治疗后再手术74例的临床分析  

Clinical analysis of open esophagastric devascularization after endoscopic therapy in 74 patients with bleeding gastroesophageal varices caused by portal hypertension

作　　者：娄诚[1] 袁强[1] 张金卷[1] 舒桂明[1] 卢诚军[1] 孙伟[1] 王毅军[1] 杜智[1] 

机构地区：[1]天津市第三中心医院肝胆外科,天津300170

出　　处：《腹部外科》2016年第3期183-186,共4页Journal of Abdominal Surgery

摘　　要：目的探讨贲门周围血管离断术治疗食管胃底静脉曲张破裂出血的最佳手术时机及术中策略。方法回顾性分析2006年1月至2015年1月天津市第三中心医院收治的180例因门静脉高压出血行选择性贲门周围血管离断术的临床资料。依据手术时机,选取术前有内镜治疗史病人74例,分析病人临床资料,进一步区分内镜治疗次数、治疗方法,分析其与术后并发症关系,采用Clavien-Dindo外科手术并发症分级分析术后并发症。结果本组病例急诊手术率高达47.30%,肝功能Child-Pugh C级病人占17.57%,所有Child-Pugh C级病人均为急诊手术,术后总体并发症发生率为43.24%,无围手术期死亡。进一步分析,术前经历≥3次内镜治疗较<3次治疗病人具有更高的并发症发生率(<3次28.57%,≥3次62.50%,P<0.05);术前经历以组织胶为核心的单独或联合治疗病人手术更加困难,与术前单纯内镜下曲张静脉套扎术治疗相比,其手术并发症发生率更高(单纯内镜下曲张静脉套扎术组为32.61%,以组织胶为核心组为60.71%,P<0.05),其中Ⅲ、Ⅳ级严重并发症增加显著。结论虽然药物及内镜治疗是食管胃底静脉曲张破裂出血的一线方案,但以选择性贲门周围血管离断术为代表的手术治疗仍占据重要地位。临床上,应尽早识别内镜治疗风险高、效果不佳或不适宜内镜治疗的病人,及时手术,术中精确操作,合理选择术式,以进一步提高疗效。Objective The aim of this study was to explore the optimal timing of surgery and in- traoperative strategy of pericardial devascularization in patients with gastroesophageal variceal bleed- ing. Methods Between January 2006 and January 2015, 180 patients with gastroesophageal variceal bleeding undertook selective pericardial devascularization in Tianjin Third Central Hospital. Based on the timing of surgery, 74 patients of all were set as clinical research targets due to their history of en- doscopic therapy. Clinical characteristics of these patients were analyzed. Furthermore, the correlation among postoperative complications, endoscopic surgery times and therapeutic methods was analyzed. Postoperative complications were evaluated using Clavien-Dindo surgical complication classification system. Results 47. 30% of targeted patients underwent emergency surgeries, in which the patients with Child-Pugh C grade accounted for 17. 57%. The overall postoperative complication rate was 43. 24% with no deaths. Further analysis indicated higher incidence of complication in patients under- going preoperative endoscopic therapy more than three times, compared with those undergoing two times of preoperative endoscopic therapy or less. Compared with patients with preoperative alone EVL, those undergoing preoperative endoscopic glue injection presented more difficult to operate and had more higher incidence of postoperative complication, especially serious grade Ⅲ and Ⅳ of compli- cations. Conclusions Although drugs and endoscopic therapy are regarded as the first-line therapy, the surgery, especially the selective pericardial devascularization, still plays an important role in in patients with gastroesophageal varices bleeding. Patients with high-risk, ineffective or inappropriate en- doscopic therapy should undertake surgery in optimal timing, using reasonable procedure and precise operating, aiming to harvest satisfactory clinical outcome.

关 键 词：食管胃静脉曲张 出血 内窥镜治疗 再手术 

分 类 号：R657.34[医药卫生—外科学]